LETTERS Back to Bedlam
Sir: In a long denunciation of care in the community, Alasdair Palmer (`Carnage in the community', 7 May) cannot bring him- self to say outright that we should go back to locking up the insane in huge mental asy- lums. Unless this was simply an oversight, it may mean that he at least recognises the complexities of this issue.
To depict care in the community as a failed remnant of 1960s political correct- ness is neither helpful nor realistic. We need a much more thoughtful debate about the diverse needs of people with different forms of mental illness. Even though, as Mr Palmer says, community care is 30 years old, too many of the issues which surround mental illness remain inadequately explored.
The lack of debate is reflected in the con- sistently low priority which care for the mentally ill has been given over the period since Enoch Powell (not, incidentally, a name I had previously associated with Six- ties liberal thinking) began the policy of closing long-stay mental hospitals. As Sec- retary of State for Health I have sought to tackle this problem, I shall continue to use the powers I have to redress the balance of spending, even where re-ordering priorities means the difficult task of 'reducing the duplication of specialist hospital services, for example in inner London.
The last 18 months have seen an increased awareness of the problems sur- rounding mentally ill people and their fami- lies. The debate has moved on. At the beginning of last year I argued that the pendulum had swung too far. We had become captured by the belief that any attempt to supervise mentally ill people in the community was an unacceptable, even authoritarian, intrusion into their civil rights. This was the tenor of my evidence to the Health Select Committee inquiry into community supervision orders — which was criticised in some quarters. It led directly to the proposals which I have put forward for tightening community care. Those mea- sures include: supervision registers of those most at risk; a new power of supervised dis- charge (which requires legislation), which will ensure immediate action when patients `Crime doesn't pay. But selling your story to the press might.' do not comply with the terms of their dis- charge, including recall to hospital if the patient's condition warrants it; clearer guid- ance making clear that patients must not be discharged from hospital unless and until those responsible are satisfied that the patient can live safely in the community, and that proper supervision and care are available.
These proposals are underpinned by the need for a change of attitude in which nec- essary control and containment are recog- nised as being as important as care and sup- port. It is a wholly perverse reaction, as has happened in more than one well-publicised case, for a patient to be ejected from care altogether because he is violent or difficult.
We also need to focus efforts and spend- ing on that small minority of most vulnera- ble patients who are a potential risk to themselves or to others. Mental illness is a clinical problem. Its sufferers can often be treated in the community. The vast majori- ty, including most people with schizophre- nia, present no danger to themselves or to the public. They do not need the sort of intensive care that Mr Palmer describes. Our task is to ensure that those few who do need that level of support receive it.
Mr Palmer is wrong to say that care in the community has been driven by the desire to save money. It is not a cheap option. It was a policy built on the belief that we owe people with mental illness something better than incarceration, possi- bly for life, in cold and remote institutions with no effective outside surveillance. Indeed, the policy followed, rather than preceded, the good practice initiated by clinicians in this country over many decades. It is a sign of how much more enlightened we have become that in a sur- vey last year three out of four people said that it was a policy they supported.
We spend £2 billion a year on services for mentally ill people. We do need to look again at the range of services that money buys to ensure that that minority of people with schizophrenia at risk are better provid- ed for. We need to recognise the rights of mentally ill people to lead lives as normal as possible in the community and the pub- lic's rights to be protected. What we do not want is a wholesale retreat back to Bedlam, simply because some would rather lock up those whose problems they either do not, or wish not, fully to understand.
Virginia Bottomley MP
Richmond House, 79 Whitehall, London SW1
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